Inspection Report Summary
The most recent inspection on June 9, 2025, identified a deficiency related to medication administration involving a nicotine patch. Earlier inspections showed a mix of compliance and deficiencies, with prior issues including medication management, wound care, care planning, and Life Safety Code concerns such as improper disposal of cigarette butts and ventilation problems in the laundry room. Complaint investigations were mostly unsubstantiated except for one substantiated medication administration issue in the latest report. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history indicates some ongoing challenges with medication and care processes, but also periods of full compliance and corrective actions following citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 1
Date: Jun 9, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460697, IN00460788, and IN00461234 at Clinton Gardens.
Complaint Details
Complaint IN00460697 and IN00461234 had no deficiencies related to the allegations. Complaint IN00460788 was substantiated with federal/state deficiencies cited at F755 related to medication administration.
Findings
The facility failed to ensure a physician-ordered medication, specifically a nicotine patch, was administered and documented appropriately for 1 of 3 residents reviewed. Deficiencies related to complaint IN00460788 were cited, while no deficiencies were found for the other complaints.
Deficiencies (1)
Failure to ensure a physician ordered nicotine patch was administered and documented appropriately for Resident B.
Report Facts
Census: 71
Total Capacity: 71
Medicare residents: 3
Medicaid residents: 45
Other payor residents: 23
Nicotine patches shipped: 30
Nicotine patches remaining: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report as facility representative |
| QMA 3 | Interviewed regarding failure to administer nicotine patch and documentation errors | |
| QMA 6 | Assisted with medication count for Resident B's nicotine patches | |
| DON | Director of Nursing | Interviewed regarding medication administration and documentation practices |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456102.
Complaint Details
Complaint IN00456102 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 48
Other census: 16
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452882.
Complaint Details
Complaint IN00452882 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 72
Total census: 72
Medicare census: 4
Medicaid census: 44
Other payor census: 24
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442505 and IN00445067.
Complaint Details
Complaint IN00442505 - No deficiencies related to the allegations are cited. Complaint IN00445067 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00442505 and IN00445067 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 66
Total census: 66
Medicare census: 4
Medicaid census: 45
Other payor census: 17
Inspection Report
Re-Inspection
Census: 70
Capacity: 100
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
A Post Survey Revisit to the Life Safety Code Recertification and State Licensure Survey conducted on 08/29/24 by the Indiana Department of Health.
Findings
Clinton Gardens was found in compliance with Requirements for Participation in Medicare, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered and had appropriate fire alarm and emergency generator systems.
Report Facts
Facility capacity: 100
Census: 70
Inspection Report
Life Safety
Census: 67
Capacity: 100
Deficiencies: 1
Date: Aug 29, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a), respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to improper disposal of cigarette butts in the designated staff smoking area. The cigarette butts were cleaned up and education was provided to staff regarding safe smoking practices.
Deficiencies (1)
Failed to ensure cigarette butts were properly disposed of at the staff smoking area, with over 10 cigarette butts found on the ground around the table by the generator.
Report Facts
Facility capacity: 100
Census: 67
Number of cigarette butts observed: 10
Staff potentially affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding cigarette butt disposal deficiency |
Inspection Report
Renewal
Census: 64
Capacity: 64
Deficiencies: 4
Date: Aug 16, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 12 to August 16, 2024.
Findings
The facility was found deficient in several areas including failure to complete self-administration medication assessments, untimely care plan meetings for residents, improper wound care by Qualified Medication Aides, and medication storage violations including presence of personal drinks and expired medications.
Deficiencies (4)
Failure to ensure a self-administration assessment had been completed for a resident observed self-administering medications.
Failure to ensure care plan meetings were completed timely for 2 of 24 residents reviewed.
Qualified Medication Aide failed to follow proper standards of practice for pressure ulcer care.
Medication storage areas contained personal drinks and expired medication was not disposed of properly.
Report Facts
Survey dates: 5
Census: 64
Total capacity: 64
Residents reviewed for care plan meetings: 24
Days QMA documented dressing changes: 4
Pressure ulcers: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report |
| LPN 16 | Licensed Practical Nurse | Interviewed regarding medication storage and medication administration |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding expired eye drops and medication administration |
| QMA 3 | Qualified Medication Aide | Interviewed regarding wound care and dressing changes |
| QMA 7 | Qualified Medication Aide | Interviewed regarding scope of practice for dressing changes |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration and wound care policies |
| Social Services Director | Social Services Director | Interviewed regarding care plan meetings documentation |
| Administrator | Administrator | Interviewed regarding care plan meetings and medication storage policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed wound dressing changes and interviewed regarding dressing documentation |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on August 16, 2024.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434905, IN00431675, and IN00430530 at Clinton Gardens.
Complaint Details
Complaints IN00434905, IN00431675, and IN00430530 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00434905, IN00431675, and IN00430530 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF beds: 65
Total census: 65
Medicare census: 4
Medicaid census: 43
Other payor census: 18
Inspection Report
Re-Inspection
Census: 66
Capacity: 100
Deficiencies: 0
Date: Jul 25, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/20/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Clinton Gardens was found in compliance with Medicare participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered and equipped with appropriate fire alarm and emergency generator systems.
Report Facts
Facility capacity: 100
Census: 66
Inspection Report
Life Safety
Census: 66
Capacity: 100
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 06/20/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to a deficiency involving the heating device in the laundry room. Specifically, the fuel-fired dryers' fresh air intake was almost fully covered, obstructing combustion air from outside, which could create a hazardous atmosphere.
Deficiencies (1)
The facility failed to ensure 1 of 1 laundry rooms was provided with intake combustion air from the outside for rooms containing fuel fired equipment, as the fresh air intake was almost fully covered with plywood and lint.
Report Facts
Facility capacity: 100
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Named in relation to review of findings at exit conference |
| Maintenance Director | Interviewed regarding the deficiency with the heating device air intake |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 6
Date: Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00405733.
Complaint Details
Complaint IN00405733 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in multiple areas including resident dignity, activities of daily living care, skin condition documentation, catheter care, medication management, and food safety practices. Complaint allegations were not substantiated. Corrective actions and staff education were implemented for all deficiencies.
Deficiencies (6)
Facility failed to ensure residents were addressed in a dignified manner for 3 residents.
Facility failed to ensure Activities of Daily Living (ADL) care were completed for 4 residents.
Facility failed to document, report, and address a skin condition on a resident.
Facility failed to ensure a resident's urinary catheter drainage bag did not touch the floor and proper procedure was followed when changing drainage bags.
Facility failed to ensure pharmacy recommendations were addressed and initiated for 2 residents.
Facility failed to ensure proper food handling and handwashing during dining observations.
Report Facts
Census: 64
Total Capacity: 64
Pharmacy Recommendations: 2
Residents reviewed for ADL care: 24
Residents with ADL deficiencies: 4
Residents reviewed for dignity: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed report and involved in policy review |
| Dementia Care Director | Interviewed regarding resident addressing practices | |
| Certified Nursing Assistant 12 | CNA | Interviewed regarding ADL care for Resident 57 |
| Certified Nursing Assistant 15 | CNA | Interviewed regarding ADL care for Resident 15 |
| Certified Nursing Assistant 7 | CNA | Interviewed regarding nail care responsibilities |
| Licensed Practical Nurse 9 | LPN | Provided information about skin injury incident |
| Certified Nurse Aide 3 | CNA | Observed and interviewed regarding catheter care |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and policies |
| Executive Director | ED | Interviewed and provided facility policies |
| Culinary Manager | Interviewed regarding food handling and handwashing |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 6, 2023.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00384800.
Complaint Details
Complaint IN00384800 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of Complaint IN00384800. The complaint was unsubstantiated due to lack of evidence.
Report Facts
Census: 58
Total Capacity: 58
Medicare Residents: 5
Medicaid Residents: 42
Other Payor Residents: 11
Report
Aug 11, 2025
Report
Jun 10, 2025
Report
Aug 16, 2024
Report
Jun 6, 2023
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